Medicines 6 Flashcards
What is the starting dose for metformin?
For standard-release metformin tablets:
500 mg with breakfast for at least 1 week, then 500 mg with breakfast and evening meal for at least 1 week, then 500 mg with breakfast, lunch, and evening meal thereafter; maximum dose 2 g daily (in divided doses).
For modified-release metformin tablets:
Initially 500 mg once daily, then increased if necessary up to 2 g once daily, dose increased gradually, every 10–15 days, dose to be taken with evening meal.
Alternatively, dose increased to 1 g twice daily, dose to be taken with meals, alternative dose only to be used if control not achieved with once daily dose regimen. If control is still not achieved, then change to standard-release tablets.
What are the symptoms that an adult patient would likely present with, to enable the diagnosis of sepsis (3 marks)? When recording a patients’ observations on a NEWS chart, what score should make you ‘think sepsis’?
(b) Likely symptoms (3 marks)
· Slurred speech (1/2 mark)
· Extreme shivering or muscle pain (1/2 mark)
· Passing no urine in a day (1/2 mark)
· Severe breathlessness (1/2 mark)
· Skin mottled or discoloured (1/2 mark)
· Patient feeling like they are going to die (1/2 mark)
NEWS score of ≥3 – think sepsis (1 mark)
Outline the current treatment protocol for sepsis (4 marks)
· Current treatment relies on the Sepsis 6 pathway (1 mark)
· Administer high flow oxygen if needed (1 mark)
· Give broad spectrum antibiotics (1 mark)
· Give iv fluids (1 mark)
· Provide vasopressors and /or other organ support as required (1 mark)
What medications are found in anticipatory medicines boxes and why?
- Cyclizine/metoclopramide (antiemetic) - nausea and vomiting
Cyclizine and metoclopramide not given together it cancels each other out
- Midazolam (Benzodiazepine)/ haloperidol (antipsychotic), usually given to treat agitation
levomepromazine (antipsychotic) - Severe agitation, nausea and vomiting
- Hysocine hydrobromide/Glycopyrronium (Antimuscarinics) - usually for chest secretions
morphine/diamorphine for pain
What are Severe sepsis and septic shock defined as?
Severe Sepsis: sepsis with the dysfunction of one or more organ systems
Renal failure for example
Septic Shock: is the final stage where hypotension persists despite adequate fluid resuscitation
Describe how sepsis alters (i) absorption, (ii) distribution, (iii) metabolism, and (iv) excretion and, for each of (i) to (iv), the advice you would give to the company with regard to the rational design of a new antibiotic taking the altered pharmacokinetics into consideration
- Absorption – decreased gastric and s/c absorption (GI system is non-essential and therefore often the first organ system to be shut down by the body, disseminated intravascular coagulation means reduce blood flow/supply to smaller vessels / peripheral system). (1 mark)
- This coupled with the desire for a rapid onset of action means company will need to formulate drug for administration via IV route. (1 mark)
- Distribution – Volume of distribution is higher in sepsis patients as a consequence of fluid resuscitation. (1 mark) (This can be problematic if antibiotic is particularly hydrophilic (e.g. beta-lactams / aminoglycosides). Lipophilic antibiotics such as fluoroquinolones / macrolides are less affected.)
- Company therefore need to consider relative hydrophilicity / lipophilicity of molecules they are synthesising. (1 mark)
- Metabolism – hepatic metabolism often altered / impaired, with phase 1 (CYP mediated) mechanisms being greatly affected by failure of the hepatic system. (1 mark)
- Need to consider likely route of metabolism for new drug. (1 mark)
- Excretion – significant changes often seen in renal function / urine output in sepsis patients. (1 mark) Want to rapidly achieve a therapeutic concentration without causing toxicity so will need to consider loading vs. maintenance dose. Dosing regime will depend on clearance rates (1 marks)
HOW TO SPOT SEPSIS IN CHILDREN
Is breathing very fast
Has a ‘fit’ or convulsion
Looks mottled, bluish, or pale
Has a rash that does not fade when you press it
Is very lethargic or difficult to wake
Feels abnormally cold to touch
A child under 5 may have sepsis if he or she:
Is not feeding
Is vomiting repeatedly
Has not passed urine for 12 hours
What are the important Renal levels to know with metformin use?
Before starting treatment with metformin, check renal function.
Do not start metformin treatment if estimated glomerular filtration rate (eGFR) is less than 30 mL/min/1.73 m2.
Stop treatment with metformin:
If eGFR is less than 30 mL/min/1.73 m2.
Review the dose of metformin if eGFR is less than 45 mL/min/1.73 m2
Which antidiabetic medication is contraindicated in history of heart failure?
Pioglitazone
Contra-indications
Contra-indicationsFor pioglitazone
Diabetic ketoacidosis; history of heart failure; previous or active bladder cancer; uninvestigated macroscopic haematuria
MHRA/CHM advice: Pioglitazone cardiovascular safety (December 2007 and January 2011)
Incidence of heart failure is increased when pioglitazone is combined with insulin especially in patients with predisposing factors e.g. previous myocardial infarction. Patients who take pioglitazone should be closely monitored for signs of heart failure; treatment should be discontinued if any deterioration in cardiac status occurs.
Pioglitazone should not be used in patients with heart failure or a history of heart failure.
If metformin is not effective as a monotherapy what would be the next steps?
If monotherapy is ineffective, consider adding one of the following:
A DPP-4 inhibitor (gliptins). - Metformin plus a DPP-4 inhibitor was moderately effective in controlling blood glucose levels and was associated with fewer hypoglycaemic events and may be beneficial in weight loss.
Pioglitazone. Metformin plus pioglitazone was most effective at reducing HbA1c levels at 24 months and preventing nausea but was associated with weight gain.
A sulfonylurea.
An SGLT-2 inhibitor — this may be considered in people taking metformin if a sulfonylurea is contraindicated or not tolerated, or the person is at significant risk of hypoglycaemia or its consequences.
If a GLP-1 receptor agonist is added for people on insulin based treatment what medications should be changed or stopped?
Note: if a GLP-1 receptor agonist is added to insulin or an insulin secretagogue (sulfonylurea or meglitinide), consider reducing the dose of the latter agents to reduce the risk of hypoglycaemia. If a DPP-4 inhibitor is being taken, it should be discontinued on starting a GLP-1 receptor agonist, as the combination does not provide additional blood glucose control.
What is the normal dose of carbimazole for hyperthyroidism?
Hyperthyroidism
for carbimazole
By mouth
Adult
15–40 mg daily continue until the patient becomes euthyroid, usually after 4 to 8 weeks, higher doses should be prescribed under specialist supervision only, then reduced to 5–15 mg daily, reduce dose gradually, therapy usually given for 12 to 18 months.
Hyperthyroidism (blocking-replacement regimen) in combination with levothyroxine
for carbimazole
By mouth
Adult
40–60 mg daily, therapy usually given for 18 months.
What is Propylthiouracil indicated for and what advice is given to the patient regarding it?
Hyperthyroidism
for propylthiouracil
By mouth
Adult
Initially 200–400 mg daily in divided doses until the patient becomes euthyroid, then reduced to 50–150 mg daily in divided doses, initial dose should be gradually reduced to the maintenance dose.
Patients should be told how to recognise signs of liver disorder and advised to seek prompt medical attention if symptoms such as anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice, dark urine, or pruritus develop.
What is cabocystiene used for and when is it cautioned/contraindicated?
Reduction of sputum viscosity
Contra-indications
Contra-indications For carbocisteine
Active peptic ulceration
Cautions
Cautions For carbocisteine
History of peptic ulceration (may disrupt the gastric mucosal barrier)
Why should alendronic acid be be swallowed whole, not crushed, chewed, or dissolved
If chewed or crushed it will have more contact with the eosopgheal tract leading to side effects
